Call Me Iron-Woman

INFeD doesn't look like Dr. Pepper being
pumped into my veins, but it's still thick
enough to cause a noticeable burn.

I'm not the average pregnant woman. My version of morning sickness is low-level nausea that lasts for about two weeks, peaks on one day where I can't stand the thought of eating anything and then goes away never to return again.

What hits me like a ton of bricks in my first trimester is fatigue -- extreme fatigue. I'm in bed by 8 p.m. and my body feels leaden when the alarm goes off at 6 a.m. Once I found out that my state of exhaustion was related to pregnancy and not just my post-35 self having a hard time adjusting to the time change, I didn't give my fatigue much thought.

Then it got worse. Not only was I constantly exhausted but I was having a hard time making it through the day. I had a difficult time concentrating on what normally would have been the simplest of conversations. I had difficulty standing for moderate periods of time and would get winded walking short distances. Even talking would take my breath away and leave me gasping for air as if I had just gone for a run.

I mentioned it to my doctor and a quick set of labs showed that what I was experiencing was more than just first-trimester fatigue. I was anemic -- again. But true to form, I wasn't just a little anemic. I never do anything just half-way. In one month, my total iron count had gone from 27 to -1, and my hemoglobin dropped from 11.8 to 9.4. Though 9.4 isn't quite in the danger zone (that's below 9), 11.7 is the lowest of the normal range so dropping that far that fast isn't a good thing.

This is Kim, my infusion nurse. My teeny-tiny
veins still intimidate her after four years, but
we've become friends through the adversity.

Thinking I could get ahead of the curve, I started taking a double dose of Floradix (40 mg iron), which is a food-based liquid iron supplement. It's not cheap and it tastes dreadful, sort of like rust-covered beets with a hint of berry. Oh...and it didn't work well enough to make it worth the investment. After two weeks, my iron went up to 4 and my hemoglobin to 9.5. At that rate, I'd be anemic until my third trimester.

The thing with anemia is that most people think it's no big deal. They tell you to eat steak and spinach or switch to cast-iron pans for cooking. I'm sure those things work for some people but not for me. The reality is that absorbing and storing iron has been a challenge for me every since my bowel obstruction in 2007.  And true anemia (i.e. hemoglobin level below 11.7) is not something to mess with. Anemia robs your blood cells of oxygen, causing them to shrink in size. That means your vital organs are also robbed of oxygen.

As an expectant mom, if I'm not getting the oxygen I need, guess who else isn't? Many anemics suffer heart damage and cardiac disease at a young age. Some suffer neurological disorders from having their brains starved of oxygen. And to add to the fun, there is no cure -- only treatments.

If you think Benadryl knocks you out in pill form, you
should try it in an IV. Instant spinning room and lights
out. Unfortunately, drugged sleep is not quality sleep. The
hoodie helps with the shivers/chills caused by the other meds.

Luckily, iron-deficiency anemia is fairly easy to treat. For most of the population, a diet rich in iron (eggs, beans, dark-green vegetables, etc.) and an oral iron supplement with Vitamin C and B-12 is all that's needed to boost hemoglobin once again.

And then there is me.

The best course of action when I am anemic is iron infusions. My routine of green juices and green smoothies kept me away from iron treatments for almost two years -- a record for me -- but even drinking the equivalent of pounds of greens each day wasn't enough to offset the deficit caused by growing another person in this body.

So back to the infusion center, I have gone. To date, I've had four treatments in what is likely to be a 10-week series. It's not fun, but it beats a sharp stick in the eye. This time, we're using INFeD, which only takes about two hours to administer. I still need the anti-nausea, anti-allergy, anti-rejection companion medications, which turn me into a zombie. The INFeD burns, but not as bad as Venofer did. The side effects of the iron itself are marginal. Some weeks, the night sweats are so bad, I have to change my clothes two or three times. Other weeks, I don't sweat at all. I get nighttime leg cramps, chills, odd nerve/skin sensations and weird short-term bouts of depression after the infusions. The upside is that all of that seems to be gone within 24 hours and I can resume normal life and normal activities.

As a result, I get a little stronger each week and so does the baby.

One Down, More to Go

After three consecutive iron treatments, I am officially no longer anemic!

My hemoglobin is 11.7 (Normal is 11.7-15.5), up from 11.2 a month ago. My ferritin level has jumped from 3 to 33 (Normal is 10-154). Much better. Not great, but good. I will take good when I can get it.

So this week, I had my fourth treatment in the spirit of a little more couldn't hurt. And now I get a break. Worst-case scenario, it only lasts a month. Best-case scenario, I won't have to worry about it for six months. Either way, I'm excited.

Now that the anemia battle has been won, we're on to other fights...otherwise known as the Battle of the B's (B1, B6 and B12). I'll keep you posted.

Pumping Iron

Ferrlecit is a fast-infusing iron supplement used to combat anemia related
to iron deficiency. Infusions are often done in chemotherapy centers.

Since my WLS "birthday" labs required further review, I went back to the hematologist who did my first round of iron infusions. Dr. Imtiaz Malik is caring, compassionate and thorough -- not always easy to find among specialists in small valley towns.

Dr. Malik is excited that my tests show some stored iron in my body. He had feared that my previous bowel obstruction would prevent my body from storing iron anymore. He is happy to be wrong. But some stored iron is still not enough stored iron and therefore, another round of iron infusions is necessary. This time around is different, though. We're trying a new type of iron that infuses faster. So instead of being tethered to an IV pole for half a day, I'm in and out in a little over an hour. I still get nauseated with the treatments, and the iron stings while it's infusing -- but those side effects are manageable and only last while I'm getting the infusions.

The challenge is dealing with the side effects that come later. Being lethargic and groggy for 24 hours from the Benadryl that is administered with the iron to prevent allergic reactions is annoying but tolerable. A little extra sleep doesn't do much harm. The hard thing for me, though, is night sweats. Yuck. Nothing worse than being awaken from drug-induced sleep to soaked jammies and sheets.

So what is the upside? Ask my friends. I've been told I'm "the old me," happier, more cheerful, more alert and "with it." Acquaintances comment on the change in my color. I suppose I'm not as pasty as before.

But for me, the benefit is much more than cosmetic or even social. The fact that I don't get killer leg cramps when walking up the stairs means I get to be the one to carry my daughter to her room at night. It means I don't have to make excuses not to play with her because I'm not as easily winded anymore.

So, yes. I am happier. I get to exercise and play with my daughter without feeling like I'm 80 years old. And all that extra oxygen that comes from having enough iron means I don't feel like my head is full of cobwebs. I can carry a simple conversation with minimal effort. Sometimes, I can even hold my own in complex conversations. I don't feel stupid. I don't feel drugged. I feel...human. And I really like the return to humanity.

The Ugly Side of Anemia

Anemia is not cool. Sure, it can give you the pasty-pale look that is so trendy in today's vampire-crazed world. But that's really the end of the coolness factor. It doesn't give you super-human strength, and it definitely doesn't make you sparkle. Instead, anemia robs your body of vital oxygen and makes you feel like everything in life takes an extraordinary amount of effort.

Vampires...much sexier than anemics.
We just look blue and gaunt.

Treating anemia can be just as grueling as living without treatment. For most people, anemia is related to low iron. Treating iron-deficiency anemia usually starts with oral supplements. Iron pills work for most people battling anemia. Unfortunately, I am not one of the lucky ones. So instead of taking pills every day, I get to have murky liquid iron injected via IV once a week. Jealous yet? It's about as glamorous as it sounds.

The first time I had infusion therapy was in late 2010. I stopped just short of a 12-week series using Venofer, which looks like Dr. Pepper pumped into your veins. Venofer was not my friend. It takes about four hours to infuse a dose, not including the pre-medication infusion of Benadryl and Zofran -- nor the 45-minute endeavor of trying to find a vein in my arm strong enough to handle the infusion. It felt like hours of my life being sucked away each week.

Then I would go home and deal with side effects. Nausea and fatigue from the drugs would send me straight to bed, where I'd pass out for four to six hours. Then I'd get up, eat a little and remain in a zombie-like state for about 36 hours. In between treatments, I'd suffer night sweats, loss of appetite from the rust-like flavor living in the back of my throat and physical pain from all of the puncture wounds on my arms. That was my life for three months. There were times when my arms were so weak from the punctures that I couldn't even hold my daughter, who was still an infant. The fact that Brian was unemployed at the time was a true blessing.

I had hoped to never go through that again. Unfortunately, my recent labs make it a necessity.

Seven Years -- No Itch

They say time flies when you're having fun, but I find it flies right by just when you're living life. At least, that's been my experience in the seven years since I had gastric-bypass surgery. My head spins when I think of all the changes I've gone through over the years. Though the physical changes are most noticeable, I think it's the emotional changes that have made the biggest difference.

I remember sitting at Kaiser South San Francisco during bariatric orientation with my first husband. Part of the program involved patients at various post-op stages describing their experiences. More than one mentioned being frustrated because they were treated differently at a new size. When I think on that now, I can't help but laugh. I am treated dramatically different than I was before, but I am not bitter about it. How can I be? I AM DIFFERENT. I think differently, talk differently and interact with the world differently than I did at 350 pounds.  I am truly half the person I used to be. I don't think it's possible to undergo that big of a physical change and not be internally affected.

February 2005: Awaiting surgery.

I used to be a great observer. I think that's why I did so well in the newspaper field. I knew how to blend into the background (not easy when you're that big) until people forgot I was there. I watched. I listened. But I didn't participate. Ask anyone, that wallflower of years past is long gone. I won't lie. I think there are many people who miss her, but most have removed themselves from my present life. I grieved for the loss of some, but others are barely a memory as I have moved on. Those who are still present in my life get limited influence. I don't have the time, nor the energy, to live in the past.

Fall 2011: Almost seven years later.

I have no regrets, and there is nothing from my old life that I miss. I don't miss only being able to shop at Lane Bryant or Torrid for clothing. I don't miss my knees hurting every day. I don't miss the amount of time or effort it took me to move throughout the world. I don't even miss chocolate cream pie, which used to be my favorite dessert in the entire world. I love my life as it is right now. I love being a wife and mother. I love being an active volunteer. I love the fact that I have the energy necessary to do do all of those things and still run my own business.

When I think about it, there isn't much about my current reality that I don't relish. I feel fortunate that the tool of surgical weight loss gave me the freedom that I enjoy today. I am grateful for the changes it has forced me to make and maintain. Experts say any weight loss maintained after two years is a credit to the patient's hard work and commitment to permanent lifestyle change. If that's true, then I deserve a pat on the back. If it's not, then I owe a debt of gratitude to Kaiser, Dr. P. Legha, and the surgical team that made it all possible. Regardless, I have a deep sense of appreciation for the life I lead today, and the physical ease at which I live it.

36-Week Update

It's hard to believe that I'm in the home stretch of my pregnancy. It feels like just yesterday when I was bowled over by the news that I was expecting.

Brian and I have had a lot of fun over the past nine months, planning and preparing for our family to grow. Just married in March, we've celebrated a lot of firsts as a married couple and lasts as a childless couple. It's been a great time all around.

Now that I'm officially nine months pregnant, there's a collective sense of relief in our home. Though we both hope Baby Kubo holds out until his/her expected arrival date of Jan. 22, we know that s/he can safely enter the world at any point now.

Our twice-weekly doctor visits have been going well, with lots of visible movement and good variation of heart rate. We had a mild contraction during our last visit, according to the monitor. I didn't feel a thing, but the fetal monitor picked it up. If I could figure out how to make it through labor without noticing my contractions, I think I might have it made.

The most exciting thing for me, however, has been the improvement in my lab results. In just one month, my hemoglobin has jumped from 8.5 to 10.5 -- proof that my anemia was caused by both iron and B12 deficiencies.

It's amazing that it's taken almost five years after having gastric-bypass surgery for me to find a doctor willing to give me B12 injections, but I'm glad I have. Those weekly B12 shots have really turned things around for me, increasing my stamina and energy, in addition to raising my hemoglobin. Double-digit hemoglobin is important. Anemics aren't just at risk for pre-term labor, but many require blood transfusions after childbirth. Not a procedure I'm interested in if I can avoid it.

What is "Ready"?
People keep asking Brian and me if we're ready for the baby yet. We're definitely ready to meet the baby, to learn his/her personality and to have the reality of parenthood fully confront us. But I find that most people aren't really curious about the emotional side of parental readiness. When they ask that question, what they really want to know is whether the nursery is in order and if we have all the baby's stuff washed and ready for action.

The answer to that is short and sweet: Nope. Not even close.

There's a lot we'd love to do in the house before Baby Kubo makes his/her debut. There are a few things we'd still like to buy. But we also know that babies are very simple creatures with simple needs for the first few months of life. They don't need skillfully decorated nurseries or perfectly arranged outfits when they come home from the hospital. They need love, attention, food and warmth. That we have covered -- everything else is just icing on the cake, so to speak.

So from now on, when people ask if we're ready, I think my answer will be short and to the point. We're as ready as we'll ever be -- and we'll adjust as needed. Baby Kubo probably won't know the difference between ready and not, and I'm pretty sure s/he won't remember much about the first year. I think we can safely relax, knowing that as long as we cover the basic needs, we're doing everything Baby Kubo expects and requires.

Tales From the Dark Side, Part II

In following up to yesterday’s post, I want to address my answer to the question, “Given the chance, would you have RNY again?”

WLS blogger Melting Mama, has a nine-minute YouTube video that explains why she wouldn’t. If you haven’t already, please watch the video (at the top of yesterday’s entry) before reading this. It’s not that MM wouldn’t have WLS, it’s just that given the choice, she would have picked an alternate procedure.

MM’s WLS journey is similar to mine in that we both went under the knife when we were in our 20s, both were over 300 pounds at the time, both had RNY and both now suffer from anemia and hypoglycemia as a direct result of that surgical procedure.

Yet now, more than three years later – four for her – we have very different views on what path we’d take if we could go back in time.

Why?

Because of one very key difference: MM was a very healthy 20-something who just happened to tip the scales at more than 300 pounds. I, on the other hand, was slowly dying in a 27-year-old fortress of fat. That’s the difference that makes our post-op experiences worlds apart.

Here’s my laundry list of pre-op concerns:

1. Chronic joint and back pain (I popped Darvocet and ibuprofen like candy);
2. High blood pressure (filled my first prescription for the condition at 21);
3. Debilitating migraines;
4. Infertility;
5. Chronic swelling;
6. Difficulty breathing;
7. Lack of mobility;

At 27, I felt like I was 80. I worked so hard to pretend the above conditions weren’t a problem and that I was “healthy” despite my weight, that I was exhausted by the end of the day. I had been morbidly obese since childhood, and my body was ready to collapse under its own weight.

After a long talk with a compassionate, yet direct, medical provider, I realized that I was on the cusp; my obesity was just beginning to catch up with me. I could continue down the path I was on and face increasingly severe co-morbidities or I could do something drastic to lose weight in an attempt to drastically reverse my course.

I chose the latter, and I haven’t had a single regret since.

Even when writhing in pain from a life-threatening bowel obstruction, I said with confidence that I would do it all over again because one day of life in a normal-size body is sweeter to me than any number in my pre-operative form.

But let’s get two things clear:

1. I DO NOT feel that way, because I’m “thin.” Go back and read my early posts – from before I had surgery – and you will see that I was terrified of being thin. It was a foreign concept to me at the time, something I could not wrap my brain around.
2. Surgery wasn't a cure-all for me. I still suffer from some of my pre-operative health concerns; they are just easier to manage at this size.
   

At the end of the day, my life is truly better now than it was in 2004 when I started my journey.

In my opinion, MM is not a whiner. Every word she says is true. We just have a different perspective on our situations. MM is right on the money when she calls WLS a trade-off. You give up obesity in exchange for other concerns or issues. In her case, the juice isn't worth the squeeze. In mine, it is.

She may not have had a bowel obstruction, but her hypoglycemia and nutritional deficiencies are much more severe than mine; I don’t suffer seizures nor do I need round-the-clock glucose monitoring. I also think that I’ve gotten more diligent after-care than she has – even when that bowel obstruction went misdiagnosed for six freaking months.

And I will say one thing very plainly: Reactive hypoglycemia is a nightmare.

MM says it best with the succinct comment, “Yeah, I look good. But what does that matter if I’m dead?”

If I ever came close to regretting bariatric surgery, it was when I became hypoglycemic. It’s difficult to articulate what it’s like other than to say it feels like your body is your enemy. Between that and the anemia presenting themselves at the same time, I felt like I was at the brink of insanity. The emotional and physical toll of hypoglycemic episodes were debilitating for me until brought them under control with the help of a caring, knowledgeable doctor a few months ago.

This last year has really been tough. I won’t lie. But in my situation, morbid obesity was still tougher.

Pumping Iron

I'm just wrapping up week three of my Repliva regimen. A word of warning to anyone interested in the prescription iron supplement: The pills are HUGE! The Web site, I think, makes the pills appear to be the size of birth control pills when in reality, they are the size of prenatal vitamins.

I wish I could say I feel differently now than before I started Repliva, but I don't. It still takes me 30 to 45 minutes to get out of bed in the morning. I still feel as if I'm walking underwater as I go about my day. Every little thing feels like it requires great effort. To say I'm dragging is a bit of an understatement.

Regardless, I'm still confident the Repliva will work in time, and I have yet to miss a dose.

Annual Lab Results: The Human Pin Cushion Speaks

It's that time of year again. You post-ops all know what time I'm referring to. The time when we head to the doctor a leave with a handy-dandy lab request form in hand that has more boxes marked on it than unmarked, leaving us to wonder whether it would have just been easier for the doctor to write a note saying, "Check for everything but ... "

My lab results weren't that great last year. Both my blood sugar and iron levels were low. But with my employer changing insurance providers and then me taking a new job that offered other types of insurance plans, I had a hard time keeping track of things.

I met my PCP last week and instantly liked him. Merced may have a shortage of physicians, but so far, I think the ones we do have are top notch. He ordered a full course of lab tests for me and referred me to a nutritionist to discuss my hypoglycemia.

At the lab, I struggled not fall asleep as the technician drew eight vials of blood. I made a bee-line from the lab to a food source when it was all said and done.

My results came in early this week. I wish I could say I was surprised by them, but they only served to confirm what I already knew: I'm a bit out of whack.

First the good news: My cholesterol is 167. My risk level for cholesterol-related heart disease is 0.67. Average risk is 2.34-4.13. My doc is very happy. The nutritionist says I can eat all the cheese I want. Must be why I like her so much ;-)

Now for the not-so-good news: I have mytocytic anemia, most commonly referred to as iron-deficiency anemia. Most common, most easy to treat. The main concern is that I've been supplementing daily yet my iron levels are half of what they were a year ago, and my organs are not getting the oxygen they need. This is why I'm so tired and why I can't sustain physical activity for very long.

Here are my results for perspective:
Ferritin -- 1 (normal is 10-154)
Total Iron -- 22 (normal is 40-175)
Hemoglobin --- 10 (normal is 12-15)

Thought my ferritin level is in the toilet, the nutritionist I saw today said she doesn't recommend infusion therapy unless total iron is 10 or less, or hemoglobin is 7 or less. It's her opinion (she's also a family practitioner) that I can afford to try a higher dose of oral therapy for six weeks to see if that improves my levels. If it doesn't, then she'll combine oral therapy with weekly injections. Transfusion will be her last course of action. We will continue to monitor my iron levels every six weeks until I get in the normal range.

I've been taking 20mg of chewable iron daily. She's prescribing a new type of iron supplement that's supposed to be really good for women in general, but has also shown great results in bariatric patients. It's called Repliva. It's set up like birth control pills, where you take one active pill a day for 21 days and then an inactive pill for 7 days. Apparently, the body absorbs iron better when it gets a little break in between supplement cycles. Repliva is said to be more bioavailable than other forms of iron, because it contains B12, Vitamin C and Succinic Acid, which all act as binders to improve absorption. So, in theory, my body will absorb all 150mg of my daily dose. It's available by prescription only, and there is a chance that my insurance company won't cover it. But if it's not covered, I will figure something out. I can't afford not to supplement my iron intake. I'm not the type of person to cut corners when it comes to my health.

I really like my nutritionist. She gave me a glucometer so I can test my blood sugar levels daily and also gave me a plan of action on how to better control my hypoglycemia. I feel like she really took her time explaining reactive hypoglycemia to me and giving me additional tools to manage it. For instance, she told me that reactive hypoglycemia is much more common in the morning, which explains why I have such issues after breakfast that can lead to me ping-ponging all day to achieve balance. The solution may be as easy as eating only protein for breakfast. Following the same logic, that would mean that if I do want to indulge in a carbohydrate, dinner is the best time to do so.

Aside from logging my meals and testing regularly to find patterns, my immediate goal is to figure out how much carbohydrate my body can handle at one time and then ensuring I get a steady dose of that level throughout the day. This should alleviate my problems with fluid retention and bloating. I'm starting with 100 grams of carbs a day, split equally (20g) through my five meals. She prepared me for the need to juggle as my glucose monitoring reveals a pattern. For example, she said I might find that I have to limit my morning meals to only 10 grams of carbs but can boost my afternoon and evening meals to 30 grams.

Long story short, she did a lot to make me feel that all is not lost. That my hypoglycemia can be managed. And though it will take patience and discipline, I feel like she's willing to partner with me in figuring out my specific needs.